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Operating Room
PATIENT SAFETY PRIMERS
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STUDY
Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.
Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.
STUDY
Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.
Petrovic MA, Aboumatar H, Baumgartner WA, et al. J Cardiothorac Vasc Anesth. 2012;26:11-16.
REVIEW
Can we make postoperative patient handovers safer? A systematic review of the literature.
Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.
STUDY
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.
CONGRESSIONAL TESTIMONY
Oversight hearing on recent patient safety issues.
Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).
STUDY
Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.
Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.
STUDY
Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.
Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.
STUDY
Nature, causes and consequences of unintended events in surgical units.
van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.
STUDY
A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.
Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RA. J Surg Res. 2009;153:95-104.
NEWSPAPER/MAGAZINE ARTICLE
Surgical errors: new products, protocols help slash the risks.
Williamson JE. Healthcare Purchasing News. January 2006;30:22-25.
COMMENTARY
Right? Left? Neither!
Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.
STUDY
Variation in hospital mortality associated with inpatient surgery.
Ghaferi AA, Birkmeyer JD, Dimick JB. N Engl J Med. 2009;361:1368-1375.
STUDY
Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.
Wauben LS, Dekker-van Doorn CM, van Wijngaarden JD, et al. Int J Qual Health Care. 2011;23:159-166.
COMMENTARY
Reducing surgical complications.
Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.
COMMENTARY
Learning from adverse events and near misses.
Greenberg CC. J Gastrointest Surg. 2008;13:3-5.
STUDY
Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.
Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].
STUDY
Gossypiboma: tales of lost sponges and lessons learned.
McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.
SPECIAL OR THEME ISSUE
Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.
Amer Surg. 2006;72:985-1149
STUDY
Effect of a comprehensive surgical safety system on patient outcomes.
de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. N Engl J Med. 2010;363:1928-1937.
STUDY
Process changes to increase compliance with the Universal Protocol for bedside procedures.
Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.
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